A 53 years old black woman presents with a sudden, excruciating headache that began while sitting at her desk at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She is a smoker and her history is significant for hypertension. On examination her level of consciousness appears slightly impaired, with slow reaction time to questions, and she has third cranial nerve palsies. There are no sensory deficits or weaknesses. Fundoscopic exam reveals bilateral retinal hemorrhages. What are the most important differential diagnoses?

Of the relevant differential diagnoses, it is important to rule out sentinel hemorrhage, intracranial aneurysms, venous sinus thrombosis, arterial dissection and vasculitis.

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This post was written by Omar Rifai